Community Linkages, Referrals, & Referral Tracking

1. Community Linkages, Referrals,& Referral Tracking CHIPRA CONNECT

2. AAP Defines Medical Home • Accessible • Family-Centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally competent

3. Children with Special Health Care Needs (CSHCN) • Particular need for: • Continuity – longitudinal relationship with Primary Care Provider (PCP) • Communication – among PCP, specialists • Collaboration - linkages to community resources • Transition – planned process which starts early for youth; need for responsibilities for health care to shift as possible over time

4. Systemic Challenges • Integration of Family-Centered Principles: e.g. continuity, comprehensiveness, coordination, cultural sensitivity. • Facilitation of networking between community resources that have historically been in “silos.” • Paucity of mental health services, especially for 0 – 5 year olds.

5. Systemic Challenges (cont.) • Additional risks for children living in poverty or in foster care (continuity especially important). • Lack of reimbursement for care coordination. • Uninsured and underinsured. Many insurance/HMO plans have inadequate or deny coverage for services for CSHCN

6. Challenges for the Primary Care Practice • Treating the “whole” child: in the context of the family, the school, the community. • Adopting an Office Systems approach • Operationalizing family feedback as part of the practice system • Considering family needs as well as office needs for scheduling and logistics • Enhanced processes for CSHCN: registries, scheduling tailored for longer visits, linkages to community resources, assistance with referrals

7. Challenges for the Primary Care Practice • “Knowing the system” of public and private providers locally • Networking with community partners effectively • Maintaining continuity and communication with specialists, child care, school, …(Wraparound) • Assuring child and family role in care planning for a child/adolescent who has a chronic/complex condition

8. Referral, Community Linkages,and Feedback Relationships & Communication

9. Sustaining Change New kind of communication with community • Relationship with key partners • Networking to facilitate process beyond practice • Agreements on how to exchange information, e.g. standardized referral process/form

10. Establishing Relationships • Invite community resource representative(s) to the practice for lunch & learn re processes for communication and referrals. • Have periodic meetings with partners who provide “wraparound” services for patients and families. • Have evening “mixer” for primary providers and community mental health providers to establish contacts. • Compile contact information and identify staff to be the liaison for the practice.

11. Partner with Parents to Do Screening & Surveillance Important linkages for Medical Home: • Head Start, Early Head Start, Child Care, Preschools, Schools • Part C, Part B • Childcare/school nurses • CC4C • Home visiting nurses • Nurse-Family Partnership • Family support • Community mental health providers • LME

12. Family Contributions • Gather reviews from families regarding referral experiences • Engage families in providing information about family resources they recommend • Become familiar with family support program(s)

13. Tracking Referrals • Tickler system: manual or electronic? • Whose role? • Reminders to families • Standardized communication and feedback with specialists • Communication processes with mental health providers and the LME • ROI specifics for CDSA and schools